Transcript The Anxiety Disorders Some Practical Questions & Answers

The
Schizophrenic Patient
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
December 16, 2011
1My
aim is to offer practical insights you can put to use.
let me know whether I have succeeded when you complete your evaluation form.
2Please
Why is this important?
• About 1 in 100 people will
develop this devastating
disorder in their lifetime.1,2
• Schizophrenia is found in every
society and in every country.
• It is best thought of a group of
disorders with
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Unknown cause,
Similar presentation,
Bizarre behavior,
Hallucinations,
Delusions, and
Deterioration in overall
functioning
• You can view a brief
documentary here.
1
• After listening to this
presentation, you will be able
to answer the following
questions:
– Why is this important?
– How do these patients
present?
– What are the diagnostic
criteria?
– What is the differential
diagnosis?
– What is the treatment?
– What are some of the
treatment challenges?
This is the cancer of mental illness.
families are the experts; you are at best a caring and knowledgeable consultant.
2The
How should you behave while caring
for these patients?
• Adopt a quiet, calm demeanor.
• Isolate your own emotional
arousal.
• Avoid perceived intrusion.
• Observe carefully.
• Listen intently.
• Know the diagnostic criteria.
• Ask brief clarifying questions.
• Avoid painful exploration.
• Review available records.
• Engage the patient’s family and
social support network.
• Consider the differential
diagnoses.
1Begin
2The
• Convey understanding,
confidence and intent to help.
• Recommend the most
appropriate medications.
• Explain most common side
effects briefly.
• Explain treatment plan briefly.
• Invite questions.
• Begin educating the family
about what to expect.
• Arrange for social support.
• Communicate with
stakeholders.
• Arrange for follow up.
with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary.
only behaviors you can really control are your own!
How to schizophrenic patients
typically present?
• The patient is 22 years old.
• He is withdrawn and hesitant
to talk.
• He was brought in for
evaluation “against my will.”
• The history is obtained
primarily from his parents.1,2
• “During his senor year of
college he became more and
more convinced that his
roommates were making fun of
him.”
• “He observed that they would
cough, sneeze or look away
when he came into the room.”
1When
2One
• “When his girlfriend broke it off
with him, he decided that she
had been replaced with a lookalike.”
• “He called the police to report
her kidnapping.”
• “He stopped going to class
because he believed that the
professors were taking
thoughts out of his mind.”
• “He stopping showering and
shaving.”
• “He thought someone was
putting something in his food
and he lost weight.”
• “We just can’t reason with
him.”
families are involved, I obtain the patient’s consent and view myself as their consultant.
of my patient’s elderly mother comes in with her son every time.
What other diagnoses are included in
this category?
• Schizophrenia (lasts at least 6 months)
• Schizophreniform Disorder (lasts 1-6 months)
• Schizoaffective Disorder (includes mood
episode)
• Delusional Disorder (delusions without other
symptoms of schizophrenia)
• Brief Psychotic Disorder (1-30 days)
• Shared Psychotic Disorder (shared delusional
system)1,2
• Psychotic Disorder due to a General Medical
Disorder (GMD)
• Substance-Induced Psychotic Disorder
• Psychotic Disorder Not Otherwise Specified
(NOS)
1This
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is fairly uncommon.
was surprised by a patient with anorexia nervosa.
What are the diagnostic criteria?
• Two of more of the
following:
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Delusions
Hallucinations
Disorganized speech
Grossly disorganized or
catatonic behavior
– Negative symptoms such as
affective flattening, alogia1,2
or absence of volition
• Social or occupational
dysfunction
• Continuous symptoms for
6 months
1This
2A
is a common symptom in hospitals—and now—prisons.
mute patient suddenly told me about Rapid City, SD.
• Schizoaffective and Mood
Disorder have been ruled
out
• Substance Disorder or an
underlying General
Medical Disorder has
been ruled out.
What are some the associated
features?
• Inappropriate affect (smiling,
giggling or weird facial
expressions)
• Loss of interest or pleasure
• Dysphoric mood
• Sleep disturbances
• Abnormal psychomotor
behavior
• Diminished concentration,
memory and attention
• 80-90% of these patients
smoke
• Comorbid mental disorders
1Eminent
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Poor insight
Noncompliance
Somatic concerns
Motor abnormalities
Decreased life expectancy
Increased risk for suicide
Higher incidence of assault and
violence among males, younger
age, people with prior history
of violence and noncompliant
patients1,2
violence is very hard to predict in these patients.
patient nearly killed a patient who had attacked a fellow psychiatrist.
What are some of the differential
diagnoses?1,2
• Psychosis due to a General
Medical Condition
• Delirium
• Dementia
• Schizotypal, Schizoid and
Paranoid Personality Disorders
• Substance-Induced Psychotic
Disorder
• Substance-Induced Delirium
• Substance-Induced Dementia
1At
• Substance-Related Disorders
• Mood Disorder with Psychotic
Features
• Schizoaffective Disorder
• Depressive Disorder Not
Otherwise Specified (NOS)
• Bipolar Disorder NOS
• Delusional Disorder
• Pervasive Developmental
Disorders
a moment in time, this can be a very difficult diagnosis to make.
diagnosis becomes increasingly clear over time.
2The
What interventions should be
included in the treatment plan?
• Combination treatment
– Biological
– Psychological
– Social
• Biological
– Typical antipsychotics
• Phenothiazines
• Haloperidol
– Atypical antipsychotics1
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Clozapine
Risperidone
Olanzapine
Quetiapine
• Psychological
– Prevent harm
– Minimize stress
– Minimize risk of relapse
• Social
– Social support
– Good alliance with patient
and the family
1These
are now usually the psychiatrist’s initial choices.
What prescriptions guidelines should
you consider?
• Stage 1 Olanzapine, quetiapine or resperidone
• Stage 2 Switch to another atypical agent; for
noncompliant patients use decanoate
preparations
• Stage 3 Switch to a third atypical antipsychotic
• Stage 4 Switch to a typical antipsychotic
• Stage 5 Use clozapine
• Stage 5a Augment clozapine
• Stage 6 Augment with additional drugs and or
ECT.
1Chiles,
et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,”
Psychiatric Services, January 1999, Vol 40 No. 1
What treatment challenges can you
expect?
• These patients have a
hard time building and
sustaining a therapeutic
relationship.
• Families often burn out
and opt out.
• Noncompliance is a
constant challenge.
• Maintaining hope is not
always easy.
1One
• Setting realistic
expectations is difficult.
• These patients are often
desperately poor.1
• The medications often
seem to cause more harm
than benefit.
of my patients brought one card from his collection to each visit as a gift to my sons.
What have you learned?
• The first descriptions of schizophrenia date back to 1400 BC.
• Schizophrenia is currently viewed as a devastating group of disorders
that involve
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Deterioration from a previous level of functioning,
Characteristic symptoms involving multiple mental processes,
Typical psychotic symptoms during the active phases of the illness, and
A demoralizing, chronic course.
• Onset usually is in the patient’s teens and 20s.
• The treatment challenges are daunting.
• Antipsychotic medications are helpful but not dramatically so, and
side effects are real problems in themselves.
• Only clozapine stands out;1 the rest differ only in expense and side
effects.
• Multi-modal intervention is the key to maximizing recovery and
preventing relapse.
1Lieberman,
et. al., “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia,” The New England
Journal of Medicine, September 22, 2005, Volume 353;1209-1223 (CATIE)
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment
plan while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Phillip Roberts, DO
Sarah Porter, DO
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